HRRET Screener Survey - WORD

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

Attachment 2
Screener

Pilot Test Study for the HIV Risk Reduction Educational Tool

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840).

Pilot Test Study for the HIV Risk Reduction Educational Tool

Screener

We are asking people to be in a research study that will help us learn more about what people think about a new online tool that is being developed by the Centers for Disease Control and Prevention (CDC). If you participate in the study, you will be asked to complete a brief survey so that we can learn more about you. After you complete the survey, you will be asked to review an online HIV prevention tool developed by CDC. You will then be asked to complete another brief survey so that we can learn your opinions about the online tool. The study will take about 45 minutes to complete. The CDC in Atlanta, Georgia is funding the research.

To see if you are a good match for this study, we will need to ask you some personal questions. Some of the questions will be about your sexual orientation and your HIV status. It is your choice to answer the questions. Your answers will be kept private to the extent allowed by law. You can refuse to answer any question or stop at any time.

May we ask you the questions to see if you are a good match for this study?

            Yes, I agree to be screened                       CONTINUE

            No, I do not wish to be screened              TERMINATE

QUESTIONS

1. How old are you?

Age__________ [Terminate if under 18]

1. Don’t know [Terminate]

2. Prefer not to answer [Terminate]

2. I am …

₁ Male [Skip to item 3]

₂ Female [Skip to item 3]

₃Transgender

₈ Don’t know [TERMINATE]

₉ Prefer not to answer [INELIGIBLE]

2a. At birth, I was assigned the sex...

₁ Male

₂ Female

Intersex

₈ Don’t know [TERMINATE]

₉ Prefer not to answer [INELIGIBLE]

2b. I currently identify as…

Male

Female

Transgender Male/Transman/FTM

Transgender Female/Transwoman/MTF

Genderqueer [Terminate]

None of the above/unsure [Terminate]

Don’t know [Terminate]

Prefer not to answer [Terminate]

3. Which do you consider yourself to be?

1. Gay or homosexual

2. Bisexual

3. Straight or heterosexual

4. Other [Specify: ] [Terminate]

5. None of the above/unsure [Terminate]

6. Don’t know [Terminate]

7. Prefer not to answer [Terminate]

3. Are you of Hispanic or Latino origin?

1. Yes

2. No

5. Please indicate your race. Are you? You may select one or more races.

1. White

2. Black or African American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

5. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.

   1. Yes

   2. No

   3. Don’t Know

   4. Prefer not to answer

5. [If Question 6=1] This next question is about the result of your HIV test. What was the result of your most recent HIV test?

   1. I tested positive for HIV

   2. I tested negative for HIV [SKIP to invitation]

   3. My results were unclear [SKIP to invitation]

   4. I never got my results/Don’t know [SKIP to invitation]

   5. Prefer not to answer [SKIP to invitation]

5. [If Question 7=1] When did you first test positive?

DATE (MM/YYYY):__________

[ERROR CHECK: CANNOT BE BEFORE 1985 OR BEYOND CURRENT DATE]

Prefer not to answer

Invitation:

Thank you for answering these questions. This study is being conducted by RTI International on behalf of the Centers for Disease Control and Prevention (CDC) to get feedback on a new tool that is being developed to provide information about HIV risk, HIV prevention strategies and HIV testing. Your participation in the study would include answering a short survey (about 15 minutes), exploring the online tool, and then taking another short survey (about 15 minutes). As a token of appreciation, you will receive a $25 Amazon gift card. This is an important research effort and we appreciate your assistance.

Would you like to participate in this study?

₁ Yes [CONTINUE]

₂ No [INELIGIBLE]

Closing for Ineligible Participants:

Thank you for answering all of the questions. Those are all of the questions we have for you today. Thank you for being willing to help us.

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